Form 25-100 - Texas Annual Insurance Premium Tax Report - 2016-2017
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2AB CD
*2510000W021729*
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25-100
b.
(Rev.2-17/29)
b
Texas Annual Insurance Premium Tax Report
(Licensed Insurance Companies and Miscellaneous Organizations)
under Chapters 552 and 559, Government Code,
You have certain rights
to review, request and correct information we have on file about you.
A report must be filed even if no tax is due.
Contact us at the address or phone number listed on this form.
71100
a. T Code b
I
c. Taxpayer number
d. Filing period
e.
f. Due date
YEAR ENDING 12-31-2016
16
03-01-2017
b
b
g. Taxpayer name and tax report mailing address (Make any necessary name and address changes below.)
IMPORTANT
h.
Blacken this box if your mailing
address has changed. Show changes
1.
beside the preprinted information.
R b
i.
j.
b
b
(Whole dollars only)
.00
1. Gross life premiums or HMO revenues
1.
b
(From Form 25-205)
.00
2. Non-taxable premiums
2.
b
(Item 1 minus Item 2)
.00
3. Taxable premiums
3.
.00
4. Enter the smaller of Item 3 or $450,000
4.
0 0 8 7 5
5. Tax rate
5.
.
b
I
(Multiply Item 4 by Item 5. If less than zero, see instructions on back.) (Dollars and cents)
6. Tax due
6.
(Whole dollars only)
.00
7. Enter the premiums over $450,000
7.
0 1 7 5 0
8. Tax rate
8.
b
I
(Multiply Item 7 by Item 8)
9. Tax due
9.
(Item 6 plus Item 9)
10. TOTAL TAX DUE
10.
(Whole dollars only)
.00
11. Gross accident and health premiums
11.
b
(Not included in Item 11)
.00
12. Employee contribution for benefit plans
12.
b
(From Form 25-205)
13. Non-taxable premiums
13.
.00
b
(Item 11 plus Item 12 minus Item 13)
.00
14. Taxable accident and health premiums
14.
0 1 7 5 0
15. Tax rate
15.
.
b
I
(Multiply Item 14 by Item 15. If less than zero, see instructions.)
16. TOTAL TAX DUE
16.
(Whole dollars only)
.00
17. Gross property and/or casualty or title premiums
17.
b
(From Form 25-205)
.00
18. Non-taxable premiums
18.
b
(Item 17 minus Item 18)
.00
19. Taxable premiums
19.
(See instructions)
20. Tax rate
20.
b
(Multiply Item 19 by Item 20. If less than zero, enter 0.)
21. TOTAL TAX DUE
21.
(Total of Items 10, 16 and 21. If less than zero, enter 0.)
22. TOTAL PREMIUM TAX DUE
22.
(See instructions)
23. Credits
23.
b
24. Assessment and CAPCO credits
24.
(Item 22 minus Items 23 and 24. If less than zero, enter 0.)
25. NET PREMIUM TAX DUE
25.
26. Total prior payments
26.
(Item 25 minus Item 26)
27. PREMIUM TAX DUE AND PAYABLE
27.
* * * DO NOT DETACH * * *
Form 25-100 (Rev.2-17/29)
(See instructions on back.)
28. Penalty and interest
28.
(Item 27 plus Item 28)
29. TOTAL AMOUNT DUE AND PAYABLE
29.
b
Taxpayer name
k.
AB
l.
b
T Code
Taxpayer number
Period
b
b
b
I declare the information in this document and all attachments is true and correct
to the best of my knowledge and belief.
Authorized agent
Preparer's name (Please print)
Make the amount in Item 29
Mail to COMPTROLLER OF PUBLIC ACCOUNTS
payable to
P.O. Box 149356
Daytime phone
Date
STATE COMPTROLLER
Austin, TX 78714-9356
(Area code & number)
For information about Insurance Tax, call 1-800-252-1387.
Details are also available online at
111 A
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